Percutaneous dilation tracheostomy device and method of using

ABSTRACT

The present invention provides an improved percutaneous dilation tracheostomy device. The device is configured to include all of the required components to perform a percutaneous tracheotomy. The device includes a retractable needle and an extendable j-wire rather than having separate components as in typical percutaneous tracheostomy devices. The device includes a dilator section to expand the diameter of a patient&#39;s stoma. The device is further configured to allow an operator to perform a bubble test to alert the user that the tube is in the trachea. In addition, the device is generally more compact than typical emergency tracheostomy devices.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent ApplicationNo. 62/504,086, filed May 10, 2017, and to U.S. Provisional PatentApplication No. 62/608,232, filed Dec. 20, 2017, the contents of whichare each incorporated by reference herein in their entirety.

BACKGROUND OF THE INVENTION

Tracheostomy tubes are placed to provide airflow and ventilation to thelungs and also protect a patient's airway. Tracheostomy tubes are oftenused to replace oral endotracheal tubes (i.e. intubation) and providelong-term airway access. The procedure can be done either surgically orpercutaneously (percutaneous dilation tracheostomy, or PDT) in either anoperating room or at the bedside in the intensive care unit (Epstein,2005). A surgical airway can also be an emergent procedure for accessingthe airway when traditional endotracheal intubation is not apossibility. Compared to oral endotracheal intubation, tracheostomy hasmany physiologic benefits. These include improved patient comfort, moreefficient airway care, better oral care, and a more secure airway, whichallows for safe patient transfer out of the acute-care ICU (Epstein,2005).

The most common emergency surgical airway is a cricothyroidotomy toreduce the likelihood of anoxia and irreversible brain damage that mayoccur within three to five minutes of airway obstruction. Acricothyroidotomy is rapidly performed by placing an airway tube throughthe cricothyroid membrane to gain emergency access to the airway.Cricothyroidotomies are, however, associated with potentialcomplications including bleeding, airway instability, and inadequateventilation. Therefore, the airway tube is often quickly replaced with astandard tracheostomy in an operating room. In addition, thecricothyroid membrane is bounded by the thyroid cartilage and thecricoid cartilage, both of which are rigid members, making it difficultto dilate. As a result, this limits the size of the tube that can beplaced (Epstein, 2005).

The average dimensions of the trachea are 2.3 cm in width and 1.8 cmfrom the posterior membrane to the anterior cartilage. In addition, thetrachea is usually wider in men than in women (Epstein, 2005). In men,the tracheal diameter ranges from 1.3 cm to 2.5 cm and 1.3 cm to 2.7 cmin the coronal and sagittal planes respectively. In women, these areslightly less with diameters of 1.0 cm to 2.1 cm and 1.0 cm to 2.3 cm(Sasson, 2003). These dimensions vary with height and age. FIG. 1 showsthe backbone of the neck region and the locations of where procedureswould be performed.

Each year, over 100,000 tracheotomies are performed in the UnitedStates. The most common indications for a tracheostomy are (1)respiratory failure and need for a prolonged mechanical ventilation and(2) a neurological pathology or derangements that compromise a patient'sability to protect their airway. (Cheung & Napolitano, 2014). Suchneurologic conditions include traumatic brain injury, stroke, spinalcord injury, anoxic brain injury, or other neurologic pathology that maycompromise a patient's airway.

Traditionally, a surgical tracheotomy procedure is performed by asurgeon at the level of the proximal trachea usually between the secondand fourth tracheal rings. The surgical procedure requires an incisionand a careful subsequent dissection through the soft tissue and musclesin the anterior neck to access the trachea. One of various techniques isthen used to create the tracheotomy, dilate this hole, and carefullyinsert the tracheostomy tube without compromising the patient's airway.This procedure can be time-consuming and is often associated withvarious risks including anoxia, infection, and bleeding.

A percutaneous tracheostomy device can simplify the procedure and reducesome of the risks by entering the trachea with minimal invasiveness.Other advantages include that it is relatively simple to perform, ofteninvolves a shorter procedure time, and may be performed bedside in anintensive care unit. The ability to perform a bedside procedure reducesthe potential morbidity associated with transport of critically illpatients to the operating room. Several studies have also shownpercutaneous tracheostomy to be more cost effective than surgicaltracheostomy with similar or lower complication rates (Cothren, 2001).

The typical percutaneous dilatational tracheostomy (PDT) method wasintroduced in 1985 by Ciaglia (Byhahn, 2000). Since then, PDT hasundergone a number of refinements and become just as safe and morecost-effective as surgical tracheostomies. Currently, manytracheostomies in intensive care medicine are done via PDT (Byhahn,2000). When performing percutaneous dilatational tracheotomy, thetracheostomy (PDT) should be placed between the second and thirdtracheal rings (Epstein, 2005). PDT includes inserting multiple dilatorsof increasing size. On average, it takes more than six minutes toperform a PDT (Byhahn, 2000).

Precautions must be taken to avoid puncturing of the posterior wall ofthe trachea on initial needle cannulation. The recommended method is toinsert the needle at 45 degrees to the long axis of the trachea pointingtowards the thorax (Muhammad, 2000). In addition, rapid dilation of thetracheostomy may result in fractures to the tracheal rings (Byhahn,2000).

The Ciaglia Blue Rhino® (CBR) is typical PDT device having a singlespecial curved dilator. PDT with the CBR requires approximately 3minutes to complete (Byhahn, 2000). The CBR kit still requires multiplecomponents and procedural actions to dilate the hole in the trachea andinsert the tracheostomy tube.

An alternative emergency tracheotomy technique is a PercuTwisttracheostomy set. The PercuTwist set uses a screw-like dilating devicethat lifts the anterior tracheal wall during dilation. A study 70 adultpatients compared the PercuTwist to the CBR technique found that half ofthe patients had CBR tracheostomies and half had PercuTwisttracheostomies. Two cases of posterior tracheal wall injury werereported from the PercuTwist method. It is also important to note thatcannula insertion was difficult in the PercuTwist cases while no suchchallenges were reported with the CBR. However, the study concluded thatthe differences were not significant and variations may be attributed tothe relative inexperience the attending physicians had with thePercuTwist method. Neither the CBR nor PercuTwist are configured for usein emergency medicine, so patients must first be transported to thehospital before the procedure can be performed.

Ensuring the correct placement of a PDT device is key to minimizingcomplications. Correct placement can be especially challenging inpatients with an abnormal tracheal anatomy. Patients with less than 1 cmbetween the cricoid ring and the upper end of the sternum are classifiedas having a short neck. In these patients, there is limited access tothe upper tracheal rings and as result, it can make it difficult toaccurately place the tracheostomy. Lastly, long shank adjustabletracheostomy tubes may need to be used for these patients becauseconventional tubes are too short (Muhammad, 2000).

Another example of altered tracheal anatomy is a deep lying trachea.Performing PDT on these patients can be hazardous as control ofhemorrhage from inadvertent puncture of a vessel deep in the neck wouldbe difficult. In addition, the trachea in these patients may also bedeviated from the midline, therefore making safe cannulation of thetrachea difficult. Lastly, anatomical landmarks may be lost, makingidentification of the upper tracheal rings and accurate cannulationdifficult. For these patients, it is recommended to perform PDT in theoperating room under general anesthesia, full monitoring, fiber-opticendoscopic control, and close surgical support (Mohammad, 2000).

Therefore, there is a need in the art for improved percutaneoustracheostomy devices. The present invention addresses this need.

SUMMARY OF THE INVENTION

In one aspect, the present invention provides a percutaneous dilationtracheostomy device comprising: a hollow casing having an elongatecylindrical proximal section and a curved tubular distal section; adepressible cylindrical plunger having a proximal end and a distal endpositioned within the proximal section of the casing, the plunger havinga lumen extending throughout; a rotatable cam positioned within theproximal section of the casing distal to the plunger, the cam having alumen extending throughout and housing a j-wire catch and a needlecatch; an elongate flexible plunger connector positioned within theproximal section of the casing distal to the cam and extending into thedistal section of the casing, the plunger connector having a lumenextending throughout; two or more hinged wall members positioned on thedistal section of the casing, the wall members being mechanically linkedto a distal end of the plunger connector; a flexible j-wire connected tothe j-wire catch at a proximal end and extendable out of the distal endof the plunger connector at a distal end; and a flexible needleconnected to the needle catch at a proximal end and extendable out ofthe distal end of the plunger connector at a distal end, the needlehaving a lumen extending throughout.

In one embodiment, the wall members are expandable between a retractedconfiguration that positions each wall member flush against the distalsection of the casing and an extended configuration that positions eachwall member equidistantly away from the distal section of the casing. Inone embodiment, the mechanical link between the plunger connector andthe wall members comprises a dilator column hingedly connected to sixstruts, each wall member being hingedly connected to two struts. In oneembodiment, the distal section of the casing comprises six openingsthrough which each of the six struts extend from the hollow interior tothe exterior of the casing. In one embodiment, the plunger isdepressible to advance the plunger connector and the dilator column in adistal direction to slide each of the six struts out of each of the sixopenings and radially extend each wall member from a retracted positionconfiguration to an expanded configuration.

In one embodiment, the plunger is depressible to rotate the cam at leasttwo steps. In one embodiment, the first rotation step is configured toextend the j-wire stop and the j-wire and to retract the needle stop andthe needle. In one embodiment, the second rotation step is configured toexpand the wall members.

In one embodiment, the plunger is mechanically linked to a dilatorcolumn hingedly connected to six struts, each wall member being hingedlyconnected to two struts, in the absence of a cam, a needle catch, aj-wire catch, and a plunger connector, such that the plunger isdepressible to radially extend the wall members.

In one embodiment, the lumen of the plunger, the cam, the plungerconnector, and the needle are fluidly connected. In one embodiment, theproximal section of the casing further comprises at least one side portfluidly connected to an aperture positioned at the distal end of thecasing. In one embodiment, the at least one side port is configured toattach to a source of ventilation gas or an end tidal CO₂ detector. Inone embodiment, the at least one side port is configured to accept theintroduction of a j-wire.

In one embodiment, the distal section of the casing has an outerdiameter between about 5 mm and 25 mm. In one embodiment, the distalsection of the casing is dimensioned to fit within the lumen of atracheostomy tube. In one embodiment, the wall members are configured todilate the diameter of the distal section of the casing by between about3 mm and 15 mm. In one embodiment, the wall members are configured tosupport an applied pressure of at least 15 MPa when expanded.

In another aspect, the present invention provides a method of insertinga tracheostomy tube into the trachea of a subject in need thereof,comprising the steps of: providing a percutaneous dilation tracheostomydevice of claim 1, the device having a tracheostomy tube fitted over thedistal section of the casing; forming an incision on the anterior neckof the subject while palpating for cartilage of the trachea; insertingthe needle of the device between the cartilage of the trachea;depressing the plunger to extend the j-wire and to retract the needle;advancing the device into the trachea such that the wall members arepositioned adjacent to the cartilage of the trachea; depressing theplunger to expand the wall members; sliding the tracheostomy tube off ofthe device and into the trachea; and removing the device from thetrachea.

In one embodiment, the step of depressing the plunger to extend thej-wire and to retract the needle is preceded by a step of inserting asyringe loaded with a fluid into the lumen of the plunger andwithdrawing the syringe to perform a bubble test. In one embodiment, thedevice is provided with a source of ventilation gas attached to a sideport on the proximal section of the casing. In one embodiment, thedevice is provided with an end tidal CO2 detector attached to a sideport on the proximal section of the casing.

BRIEF DESCRIPTION OF THE DRAWINGS

The following detailed description of embodiments of the invention willbe better understood when read in conjunction with the appendeddrawings. It should be understood, however, that the invention is notlimited to the precise arrangements and instrumentalities of theembodiments shown in the drawings.

FIG. 1A is an illustration of a patient's neck region and the points ofentry for a typical tracheotomy. FIG. 1B is an illustration of a typicalLaborde dilator.

FIG. 2 is a photograph of an exemplary percutaneous dilationtracheostomy device with a preloaded tracheostomy tube.

FIG. 3 is a schematic of an exemplary percutaneous dilation tracheostomydevice with a preloaded tracheostomy tube.

FIG. 4A through FIG. 4C depict the inner components of an exemplarypercutaneous dilation tracheostomy device. FIG. 4A is a side view of thedevice with casing removed. FIG. 4B is a perspective view of the devicewith casing removed. FIG. 4C is a cross-sectional side view of thedevice within a casing.

FIG. 5A through FIG. 5D depict the casing of an exemplary percutaneousdilation tracheostomy device. FIG. 5A is a top view. FIG. 5B is aperspective view. FIG. 5C is a side view. FIG. 5D is a cross-sectionalside view.

FIG. 6A through FIG. 6C depict half of a proximal section of the casingof an exemplary percutaneous dilation tracheostomy device. FIG. 6A is atop view. FIG. 6B is a side view. FIG. 6C is a perspective view.

FIG. 7A through FIG. 7D depict the distal section of the casing of anexemplary percutaneous dilation tracheostomy device. FIG. 7A is a topview. FIG. 7B is a perspective view. FIG. 7C is a side view. FIG. 7D isa cross-sectional side view.

FIG. 8A through FIG. 8D depict the plunger of an exemplary percutaneousdilation tracheostomy device. FIG. 8A is a top view. FIG. 8B is aperspective view. FIG. 8C is a side view. FIG. 8D is a cross-sectionalside view.

FIG. 9A through FIG. 9D depict the cam of an exemplary percutaneousdilation tracheostomy device. FIG. 9A is a top view. FIG. 9B is aperspective view. FIG. 9C is a side view. FIG. 9D is a cross-sectionalside view.

FIG. 10A through FIG. 10F depict the j-wire catch, the j-wire rotationalhold, and the needle catch components of an exemplary percutaneousdilation tracheostomy device. FIG. 10A is a top view of the j-wirecatch. FIG. 10B is a perspective view of the j-wire catch. FIG. 10C is atop view of the j-wire rotational hold. FIG. 10D is a perspective viewof the j-wire rotational hold. FIG. 10E is a top view of the needlecatch. FIG. 10F is a perspective view of the needle catch.

FIG. 11 is a cross-sectional side view of an exemplary percutaneousdilation tracheostomy device showing the locations of the j-wire catch,the j-wire rotational hold, and the needle catch components.

FIG. 12A through FIG. 12D depict the plunger connector of an exemplarypercutaneous dilation tracheostomy device. FIG. 12A is a top view. FIG.12B is a perspective view. FIG. 12C is a side view. FIG. 12D is across-sectional side view.

FIG. 13A and FIG. 13B depict the dilator of an exemplary percutaneousdilation tracheostomy device. FIG. 13A is a perspective view. FIG. 13Bis a side view.

FIG. 14A through FIG. 14D depict the column of the dilator of anexemplary percutaneous dilation tracheostomy device. FIG. 14A is a topview. FIG. 14B is a perspective view. FIG. 14C is a side view. FIG. 14Dis a cross-sectional side view.

FIG. 15A through FIG. 15C depict the strut of the dilator of anexemplary percutaneous dilation tracheostomy device. FIG. 15A is a topview. FIG. 15B is a perspective view. FIG. 15C is a side view.

FIG. 16A through FIG. 16D depict the wall member of the dilator of anexemplary percutaneous dilation tracheostomy device. FIG. 16A is a topview.

FIG. 16B is a perspective view. FIG. 16C is a side view. FIG. 16D is across-sectional side view.

FIG. 17 is a photograph of a side view of an exemplary percutaneousdilation tracheostomy device having a side port.

FIG. 18 is a flowchart listing the steps of an exemplary method ofinserting a tracheostomy tube into a patient using a percutaneousdilation tracheostomy device.

FIG. 19 is an illustration of an exemplary method of using apercutaneous dilation tracheostomy device.

FIG. 20A though FIG. 20C depict the results of simulating stresses onthe components of the dilator. FIG. 20A depicts the deformation of thewall members under an external pressure. FIG. 20B depicts thedeformation of the struts under an external pressure. FIG. 20C depictsthe deformation of the column under an external pressure.

DETAILED DESCRIPTION

The present invention provides improved percutaneous dilationtracheostomy devices. The devices increase the safety, delivery, andefficiency of a percutaneous tracheotomy for traditional and emergentcases. The improved percutaneous dilation tracheostomy devices have areduced parts count compared to typical percutaneous tracheostomy kits.The device according to a current embodiment includes a radiallyexpanding region or dilation walls to dilate a patient's trachealorifice. The device decreases the required number of steps or maneuversto insert a tracheostomy tube, thus reducing the time required to safelyperform a percutaneous tracheotomy. The device can also be used inemergency airway procedures.

The improved percutaneous dilation tracheostomy device is configured toprovide feedback to the operator during while dilating the tracheaduring the procedure. The device includes a plunger that operatesthrough mechanical pressure provided by an operator, allowing theoperator to dilate to the desired size within a specified size range ata controlled rate of expansion. The operator depresses the plunger toforce the dilator radially outward so the dilation walls press against apatient's cartilaginous tracheal rings to dilate the patient's stoma. Inone embodiment, the plunger mechanism squeezes a compressible materialoutwards to dilate the opening. The plunger also includes a lockingmechanism configured for the operator to control expansion of theopening. Thus, the operator dilates the trachea by expanding thedilation walls to a desired size.

The device is configured to include all of the required components toperform a percutaneous tracheotomy. The devices include a retractableneedle, rather than having a separate component as in typicalpercutaneous tracheostomy devices. The retractable needle is attached tothe tip of the device and the operator creates the initial puncture inthe patient's trachea and retracts the needle into the device afterentry into the patient's tracheal lumen is confirmed by a bubble test. Aguide wire is then extended which helps maintain airway accessthroughout the remaining procedure. The device gradually becomes wideralong its length to help safely initiate the dilation process andfurther secure the airway access. Finally, a dilation mechanism isconfigured to control the complete stoma dilation. The device is furtherconfigured to introduce the final tracheostomy tube so as to remove thedevice while the final tracheostomy tube remains in the patient.

General aspects of the design include ease of use, cost, and safety. Thedevice is formed of materials that are approved for medical use. Thedevice is generally ergonomic, such that it is comfortable for theoperator to use. In addition, the device is configured to be low-costsuch that it can be disposable. The devices are further configured toreduce the number of steps or maneuvers to perform a percutaneoustracheotomy by consolidating various required components into a singledevice. The device can also be used in patients requiring an electivetracheostomy.

Definitions

It is to be understood that the figures and descriptions of the presentinvention have been simplified to illustrate elements that are relevantfor a clear understanding of the present invention, while eliminating,for the purpose of clarity, many other elements typically found in theart. Those of ordinary skill in the art may recognize that otherelements and/or steps are desirable and/or required in implementing thepresent invention. However, because such elements and steps are wellknown in the art, and because they do not facilitate a betterunderstanding of the present invention, a discussion of such elementsand steps is not provided herein. The disclosure herein is directed toall such variations and modifications to such elements and methods knownto those skilled in the art.

Unless defined elsewhere, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although any methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of the present invention, exemplary methods andmaterials are described.

As used herein, each of the following terms has the meaning associatedwith it in this section.

The articles “a” and “an” are used herein to refer to one or to morethan one (i.e., to at least one) of the grammatical object of thearticle. By way of example, “an element” means one element or more thanone element.

“About” as used herein when referring to a measurable value such as anamount, a temporal duration, and the like, is meant to encompassvariations of ±20%, ±10%, ±5%, ±1%, and ±0.1% from the specified value,as such variations are appropriate.

Throughout this disclosure, various aspects of the invention can bepresented in a range format. It should be understood that thedescription in range format is merely for convenience and brevity andshould not be construed as an inflexible limitation on the scope of theinvention. Accordingly, the description of a range should be consideredto have specifically disclosed all the possible subranges as well asindividual numerical values within that range. For example, descriptionof a range such as from 1 to 6 should be considered to have specificallydisclosed subranges such as from 1 to 3, from 1 to 4, from 1 to 5, from2 to 4, from 2 to 6, from 3 to 6, etc., as well as individual numberswithin that range, for example, 1, 2, 2.7, 3, 4, 5, 5.3, 6, and anywhole and partial increments therebetween. This applies regardless ofthe breadth of the range.

Percutaneous Dilation Tracheostomy Device

The present invention provides devices configured to increase thedelivery, efficiency, and reliability of a percutaneous tracheotomy bothemergently and electively. The improved percutaneous dilationtracheostomy devices have reduced parts counts compared to typicaltracheostomy components. The devices include a radially expandingdilator region. Thus, the devices can be configured for an operator toperform a tracheostomy in conjunction with typical tracheostomycomponents, such as a scalpel to make an initial incision, a syringe toperform a bubble test, and a tracheostomy tube.

Referring now to FIG. 2 and FIG. 3 , an exemplary percutaneous dilationtracheostomy device 100 is depicted having a preloaded tracheostomy tube106. Device 100 has a proximal end 102 and a distal end 104. Visiblefrom its exterior, device 100 comprises casing 200, plunger 300, dilator700, and needle 502. FIG. 4A through FIG. 4C reveal the internalcomponents of device 100, further comprising cam 400, plunger connector600, and j-wire 508.

Referring now to FIG. 5A through FIG. 5D, casing 200 is shown inisolation. Casing 200 comprises a proximal section 202 and a distalsection 252. Proximal section 202 has a substantially cylindrical shapehaving a hollow interior and open proximal and distal ends. Distalsection 252 has a substantially tubular, curved shape having a hollowinterior, an open proximal end joined to the open distal end of proximalsection 202, and an open distal end. Distal section 252 furthercomprises a plurality of slits 260 accommodating dilator 700, asdescribed elsewhere herein. In some embodiments, casing 200 is generallysimilar to typical percutaneous tracheostomy casings, such as theCiaglia Blue Rhino®. Distal section 252 is a curved section that isshaped to accommodate pre-loading of a tracheostomy tube 106 onto device100 to efficiently introduce tracheostomy tube 106 into the tracheawhile avoiding damage to the posterior tracheal wall. Distal section 252is further shaped for an initial dilation of the stoma fromapproximately 14 Fr to 28 Fr along the curved section.

Referring now to FIG. 6A through FIG. 6C, proximal section 202 isdescribed in detail. The interior surface of proximal section 202comprises several compartments to hold the various internal componentsof device 100. For example, proximal section 202 comprises a firstregion 226 holding a portion of plunger 300. Plunger translation hold204 is provided within first region 226 as a guide to limit movement ofplunger 300 in a proximal-distal direction and to prevent plunger 300from falling out of device 100. Second region 228 comprises plungerrotation hold 206, which includes grooves for prongs 306 of plunger 300to prevent rotational movement of plunger 300. Third region 230 holds aportion of plunger 300 and cam 400. Fourth region 232 comprises camspring column 208, which holds a portion of cam 400 and has an increaseddiameter to accommodate a spring (not pictured). Fifth region 234 holdsa portion of cam 400 and plunger connector 600, and includes camtranslation catch 210 as a guide to limit the movement of cam 400 in aproximal-distal direction. Sixth region 236 holds a portion of plungerconnector 600 and includes lumen 214. In some embodiments, proximalsection 202 can be molded as a single unit, along with any internalparts, during fabrication. In other embodiments, proximal section 202can comprise two or more pieces fitted together by way of tabs 212. Insome embodiments, proximal section 202 can further include a lockingmechanism configured to temporarily lock the position of an internalcomponent, such as plunger 300.

Proximal section 202 can be constructed from any suitable material, suchas a metal or a rigid plastic or polymer. Proximal section 202 can haveany suitable dimensions. For example, proximal section 202 can have: anouter diameter between about 20 mm and 30 mm, such as about 25 mm; aninner diameter 208 between about 14 mm and 24 mm, such as about 19 mm; aplunger rotation hold diameter 220 between about 7 mm and 17 mm, such asabout 12 mm; a lumen diameter 222 between about 1 mm and 11 mm, such asabout 6.27 mm; a plunger translation hold thickness 224 between about0.5 mm and 2.5 mm, such as about 1.53 mm; a first region 226 heightbetween about 25 mm and 35 mm, such as about 30 mm; a second region 228height between about 20 mm and 30 mm, such as about 25 mm; a thirdregion 230 height between about 16 mm and 26 mm, such as about 21 mm; afourth region 232 height between about 15 mm and 25 mm, such as about 20mm; a fifth region 234 height between about 23 mm and 33 mm, such asabout 28 mm; a sixth region 236 height between about 4.5 mm and 8.5 mm,such as about 6.5 mm; and an overall proximal section height 238 betweenabout 127 mm and 147 mm, such as about 137 mm.

Referring now to FIG. 7A through FIG. 7D, distal section 252 isdescribed in detail. Distal section 252 comprises a lumen 262 extendingfrom an open proximal end and a distal tip 254, terminating in a distalaperture 256. Distal section 252 further comprises a recess 258 adjacentto distal tip 254, wherein the length of recess 258 has a diameter thatis smaller than outer diameter 264 of distal section 252. Recess 258further comprises a plurality of elongate slits 260. The number of slits260 corresponds with the number of struts 704 of dilator 700 asdescribed elsewhere herein, which can be between about 4 and 12, such as6.

Distal section 252 can be constructed from any suitable material, suchas a metal or a rigid plastic or polymer. In some embodiments, distalsection 252 can be constructed from a flexible material, such aspolyurethane. Distal section 252 can have any suitable dimensions. Forexample, distal section 252 can have: an outer diameter 264 betweenabout 2 mm and 13 mm, such as about 7.27 mm; an inner diameter 266between about 1 mm and 12 mm, such as about 6.27 mm; an outer diameter268 of distal tip 254 between about 1 mm and 3 mm, such as about 2 mm;an inner diameter 270 of distal tip 254 between about 0.5 mm and 2.5 mm,such as about 1.7 mm; a slit length 272 between about 2 mm and 8 mm,such as about 5 mm; and a recess length 274 between about 15 mm and 25mm, such as about 20.83 mm.

Referring now to FIG. 8A through FIG. 8D, plunger 300 is described indetail. Plunger 300 comprises a substantially cylindrical proximalportion having two or more prongs 306 extending from its proximalportion in a distal direction. Plunger 300 comprises a lumen 312extending through the height of plunger 300, lumen 312 being connectedto syringe port 302 at a proximal end and having an open distal end.Lumen 312 further comprises j-wire groove 310 embedded in its innersurface for guiding the movement of j-wire catch 506 in aproximal-distal direction. In some embodiments, lumen 312 comprises acompressed spring loaded between syringe port 302 and j-wire catch 506.Plunger 300 comprises one or more plunger translation grooves 304embedded in its exterior, wherein each plunger translation groove 304 issized to fit a plunger translation hold 204 of proximal section 202.Each prong 306 terminates in a prong interface 308 at its distal end.Prong interface 308 has an angled construction configured to mate withfirst cam interface 402 and second cam interface 404, as describedelsewhere herein.

Plunger 300 can be constructed from any suitable material, such as ametal or a rigid plastic or polymer. Plunger 300 can have any suitabledimensions. For example, plunger 300 can have: an outer diameter 314between about 14 mm and 23 mm, such as about 19 mm; a syringe portdiameter 316 between about 1 mm and 3 mm, such as about 2 mm; a diameter318 between about 6 mm and 16 mm, such as about 11.2 mm; a first region320 height between about 25 mm and 35 mm, such as about 30 mm; a secondregion 322 height between about 5 mm and 15 mm, such as about 10 mm; aplunger height 324 between about 70 mm and 90 mm, such as about 80 mm; aprong width 326 between about 2 mm and 6 mm, such as about 4.75 mm; anda prong thickness 328 between about 1 mm and 5 mm, such as about 3.5 mm.

Referring now to FIG. 9A through FIG. 9D, cam 400 is described indetail. Cam 400 comprises a substantially cylindrical shape havingseveral exterior features configured to mate with and actuate thevarious components of device 100. At a first region 432, cam 400comprises a diameter 428 sized to fit within the open distal end ofplunger 300 for additional stability. At a second region 434, cam 400comprises a diameter 426 sized to fit between prongs 306 of plunger 300.In some embodiments, second region 434 further comprises a spring woundaround cam 400 and touching the distal end of plunger 300. At a thirdregion 436, cam 400 comprises spring hold 408, which is configured toengage a spring within cam spring column 208 of proximal section 202.Third region 436 further comprises first cam interface 402 and secondcam interface 404. First cam interface 402 and second cam interface 404are angled surfaces that are in alignment with the angle of pronginterfaces 308, such that prong interfaces 308 are configured to slidealong first cam interface 402 and engage second cam interface 404. Thirdregion 436 further comprises translation groove 410 embedded in itsexterior, wherein translation groove 410 is sized to fit cam translationcatch 210 of proximal section 202. At a fourth region 438, cam 400comprises rotation groove 412 embedded in its exterior, wherein rotationgroove 412 is sized to fit cam translation catch 210 of proximal section202. At a fifth region, cam 400 comprises plunger connector flange 414.At a sixth region 440 and a seventh region 442, cam 400 comprisesplunger connector plug 416, which is configured to engage with plungerconnector 600, as described elsewhere herein. Cam 400 further compriseslumen 422 extending between an open proximal end and an open distal end,the proximal end having a j-wire groove 418 and the distal end having aneedle groove 420. In some embodiments, needle groove 420 ishelix-shaped, such that a needle catch 500 moving through needle groove420 is configured to rotate cam 400.

Cam 400 can be constructed from any suitable material, such as a metalor a rigid plastic or polymer. Cam 400 can have any suitable dimensions.For example, cam 400 can have: a diameter 424 between about 14 mm and 24mm, such as about 19 mm; a diameter 426 between about 7 mm and 17 mm,such as about 12 mm; a diameter 428 between about 3 mm and 8 mm, such asabout 5.5 mm; a diameter 430 between about 12 mm and 22 mm, such asabout 17 mm; a first region 432 height between about 25 mm and 35 mm,such as about 30 mm; a second region 434 height between about 15 mm and25 mm, such as about 20 mm; a third region 436 height between about 30mm and 40 mm, such as about 35 mm; a rotation groove height 438 betweenabout 3 mm and 7 mm, such as about 5 mm; a flange height 440 betweenabout 3 mm and 7 mm, such as about 5 mm; a plug height 442 between about3 mm and 7 mm, such as about 5 mm; a fourth region 444 height betweenabout 60 mm and 70 mm, such as about 65 mm; a fifth region heightbetween about 25 mm and 35 mm, such as about 30 mm; a sixth regionheight between about 3 mm and 7 mm, such as about 5 mm; and a cam height450 between about 90 mm and 110 mm, such as about 102 mm.

Referring now to FIG. 10A through FIG. 10F, needle catch 500, j-wirerotational hold 504, and j-wire catch 506 are described in detail.J-wire catch 506 comprises a hollow cylindrical shape having opposingparallel tabs attached to its exterior. J-wire catch 506 is sized to fitwithin j-wire groove 418 of cam 400 and j-wire groove 310 of plunger300. J-wire catch 506 is configured to secure the distal end of aflexible j-wire 508, such that the positioning of j-wire 508 can bemanipulated by repositioning j-wire catch 506 within device 100. J-wirerotation hold 504 comprises a substantially cylindrical shape having ahollow interior sized to fit j-wire catch 506 and opposing parallel tabsattached to its exterior. J-wire rotation hold 504 is sized to fitwithin lumen 312 of plunger 300, as shown in FIG. 11 . J-wire rotationhold 504 is a stationary component that prevents rotation of j-wirecatch 506 for the duration that j-wire catch 506 is held within itsinterior. Needle catch 500 comprises a hollow cylindrical shape havingopposing parallel tabs attached to its exterior. Needle catch 500 issized to fit within needle groove 420 of cam 400 and needle catch socket604 of plunger connector 600, as described elsewhere herein. Needlecatch 500 is configured to secure the distal end of a flexible needle502, such that the positioning of needle 502 can be manipulated byrepositioning needle catch 500 within device 100.

Needle catch 500, j-wire rotational hold 504, and j-wire catch 506 caneach be constructed from any suitable material, such as a metal or arigid plastic or polymer. Needle catch 500, j-wire rotational hold 504,and j-wire catch 506 can have any suitable dimensions. For example,needle catch 500 can have: an outer diameter 526 between about 3 mm and7 mm, such as about 5 mm; an inner diameter 528 between about 2 mm and 6mm, such as about 4 mm; a tab thickness 530 between about 0.5 and 1 mm,such as about 0.7 mm; and a tab width 532 between about 0.7 and 1.5 mm,such as about 1 mm. J-wire rotational hold 504 can have: an outerdiameter 518 between about 3.5 mm and 7.5 mm, such as about 5.5 mm; aninner diameter 520 between about 1.5 mm and 5.5 mm, such as about 3.5mm; a tab slot thickness 522 between about 0.1 mm and 1 mm, such asabout 0.5 mm, and a tab thickness 524 between about 1 mm and 3 mm, suchas about 2 mm. J-wire catch 506 can have: an outer diameter 510 betweenabout 1.5 mm and 5.5 mm, such as about 3.5 mm; an inner diameter 512between about 1 mm and 3 mm, such as about 2 mm; a tab thickness 514between about 0.1 mm and 1 mm, such as about 0.5 mm, and a tab width 516between about 0.5 mm and 1.5 mm, such as about 1 mm.

Referring now to FIG. 12A through FIG. 12D, plunger connector 600 isdescribed in detail. Plunger connector 600 comprises a lumen 606extending between a proximal cam socket 602, through an elongate andflexible tubular section, and terminating in a distal opening. Camsocket 602 is configured to engage plunger connector plug 416 of cam400. Cam socket 602 comprises needle catch socket 604 at its center,which is configured to engage needle catch 500. In some embodiments,plunger connector 600 comprises a compressed spring loaded betweenneedle catch socket 604 and a needle catch 500.

Plunger connector 600 can be constructed from any suitable material,such as a flexible plastic or polymer configured to flex with and movethrough distal section 252 of casing 200. Plunger connector 600 can haveany suitable dimensions. For example, plunger connector 600 can have: anouter diameter 608 of cam socket 602 between about 14 mm and 24 mm, suchas about 19 mm; an inner diameter 610 of cam socket 602 between about 10mm and 20 mm, such as about 15 mm; an outer diameter 612 of needle catchsocket 604 between about 2 mm and 5 mm, such as about 3.6 mm; an innerdiameter 614 of needle catch socket 604 between about 1 mm and 4 mm,such as about 2.6 mm; a lumen diameter 616 between about 3 mm and 7 mm,such as about 5.2 mm; a tab slot width 618 between about 0.5 mm and 1.5mm, such as about 1 mm; a first region height 620 between about 5 mm and13 mm, such as about 9 mm; a second region 622 height between about 60mm and 80 mm, such as about 72 mm; a third region 624 height betweenabout 3 mm and 7 mm, such as about 5 mm, and a fourth region 626 heightbetween about 1 mm and 3 mm, such as about 2 mm.

Referring now to FIG. 13A and FIG. 13B, dilator 700 is depicted. Dilator700 comprises a plurality of wall members 706 hingedly connected to acentral column 702 by way of a plurality of struts 704. Dilator 700 isassembled in device 100 such that column 702 is seated within lumen 262of distal section 252, each strut 704 attached to column 702 passesthrough a slit 260, and each strut 704 attaches to a wall member 706exterior to distal section 252. Dilator 700 has a closed configurationand an expanded configuration, wherein the closed configuration bringsthe plurality of wall members 706 together edge to edge to form asubstantially cylindrical shape within recess 258, and the openconfiguration (shown in FIG. 13A and FIG. 13B) expands the plurality ofwall members 706 away from each other radially. In some embodiments, theexpansion of wall members 706 increases the effective diameter ofdilator 700 from about 3 mm to about 10 mm.

Referring now to FIG. 14A through FIG. 14D, column 702 is described indetail. Column 702 comprises a substantially solid polyhedral shapehaving a proximal end, a distal end, and a plurality of faces supportinga plurality of hinges 712. Column 702 comprises lumen 714 running from aproximal head 710 to a distal open end. In the embodiment depicted,column 702 has three faces, each face supporting a proximal pair ofhinges 712 and a distal pair of hinges 712, for a total of twelve hinges712. It should be understood that column 702 can have as many faces andas many hinges 712 as desired, including but not limited to combinationssuch as: two faces with a proximal and distal pair of hinges 712 perface totaling eight hinges 712; four faces with a proximal and distalpair of hinges 712 per face totaling sixteen hinges 712; five faces witha proximal and distal pair of hinges 712 per face totaling twenty hinges712; and six faces with a proximal and distal pair of hinges 712 perface totaling twenty four hinges 712. Column 702 can further includefacet surfaces between each adjacent face.

Column 702 can be constructed from any suitable material, such as ametal or a rigid plastic or polymer. Column 702 can have any suitabledimensions. For example, column 702 can have: a head diameter 716between about 3 mm and 6 mm, such as about 4.5 mm; a lumen diameter 718between about 1 mm and 2 mm, such as about 1.7 mm; a head thickness 720between about 0.1 mm and 1 mm, such as about 0.5 mm; a hinge separation722 between about 5 mm and 11 mm, such as about 8 mm; a facet width 724between about 0.5 mm and 1 mm, such as about 0.73 mm; a face width 726between about 1 mm and 2 mm, such as about 1.73 mm; a column length 728between about 8 mm and 12 mm, such as about 10.67 mm; a hinge height 730between about 0.5 mm and 1.5 mm, such as about 1 mm; and a hinge holediameter 732 between about 0.1 mm and 1 mm, such as about 0.5 mm.

Referring now to FIG. 15A through FIG. 15C, strut 704 is described indetail. Strut 702 has an elongate rectangular shape and cross-sectionand rounded ends each having a hinge hole 734. Hinge hole 734 is sizedto hingedly connect to a pair of hinges 712 of column 702 and a pair ofhinges 744 of wall member 708, such as by a hinge pin. At least twostruts 704 thereby hingedly connect column 702 to each wall member 708.

Strut 704 can be constructed from any suitable material, such as a metalor a rigid plastic or polymer. Strut 704 can have any suitabledimensions. For example, strut 704 can have: a strut thickness 736between about 0.5 and 1 mm, such as about 0.75 mm; a strut length 738between about 5 mm and 11 mm, such as about 8 mm; and a hinge holediameter 742 between about 0.3 mm and 1 mm, such as about 0.5 mm.

Referring now to FIG. 16A through FIG. 16D, wall member 708 is describedin detail. Each wall member 708 has a thickness that is substantiallythe same as the depth of recess 258 of distal section 252, such thatwall members 708 can be seated in recess 258 to be flush against theouter diameter 264 of distal section 252. Each wall member 708 curvesalong arc 750, such that a plurality of wall members 708 is configuredto join edge to edge to form a substantially cylindrical shape. Thedegree of arc 750 thereby depends on the number of wall members 708 usedto form the 360° of a substantially cylindrical shape. For example, twowall members 708 can each have an arc 750 of about 180°; three wallmembers 708 can each have an arc 750 of about 120°; four wall members708 can each have an arc 750 of about 90°; five wall members 708 caneach have an arc 750 of about 72°; six wall members 708 can each have anarc 750 of about 60°; etc. Each wall member 708 comprises a proximalpair and a distal pair of hinges 744, similar to the arrangement ofhinges 712 on column 702.

Wall member 708 can be constructed from any suitable material, such as ametal or a rigid plastic or polymer. Wall member 708 can have anysuitable dimensions. For example, wall member 708 can have: a combinedouter diameter 746 of between about 4 mm and 8 mm, such as about 6.1 mm;a combined inner diameter 748 between about 3 mm and 7 mm, such as about5.1 mm; a hinge spacing 752 between about 0.5 mm and 1.5 mm, such asabout 1 mm; a hinge separation 754 between about 5 mm and 13 mm, such asabout 9 mm; a hinge thickness 756 between about 0.3 mm and 1 mm, such asabout 0.5 mm; a wall overhang 758 between about 3 mm and 8 mm, such asabout 5.5 mm; a wall member height 760 between about 15 mm and 25 mm,such as about 20 mm; and a hinge hole diameter between about 0.3 mm and1 mm, such as about 0.5 mm.

In various embodiments, device 100 can further comprise one or moremodifications to enhance its performance. For example, in someembodiments device 100 can include a side port 108 positioned onproximal section 202 of casing 200 (FIG. 17 ). Side port 108 is fluidlyconnected to distal section 252 of casing 200 or to needle 502. In someembodiments, side port 108 is configured to provide a continuous flow ofa source of fluid or gas through needle 502, such as a source of oxygenor air. Side port 108 can be compatible with typical gas or fluidcouplings to connect to a source of fluid or gas. Side port 108 can bepositioned perpendicular to the axis of proximal casing 202, or angledto minimize interference between any connected tubing, a patient, and/oran operator. Thus, side port 108 can reduce the likelihood ofcomplications associated with hypoxia (i.e., lack of oxygen) whileinserting device 100 (e.g., which may be related to a partial orcomplete airway obstruction that occurs while placing the standardpercutaneous device). Side port 108 can also be compatible with an endtidal CO₂ detector. An end tidal CO₂ detector is a monitor generallyused to confirm airway placement of an endotracheal and tracheostomytube. Thus, side port 108 can allow real-time confirmation of deviceplacement within a patient and reduce the risk of a misplacedtracheostomy tube.

The function of percutaneous dilation tracheostomy device 100 is nowdescribed. Syringe port 302 and lumen 312 of plunger 300, lumen 422 ofcam 400, lumen 606 of plunger connector 600, lumen 714 of dilator 700,and lumen 262 and distal aperture 256 of casing 200 are in fluidconnection. A needle 502 having a lumen is thereby able to pass througheach of the structures listed above, and a syringe attached to syringeport 302 has fluid access to the distal end of needle 502, enabling thesyringe to perform a bubble test.

Device 100 is configured to perform several actions through thedepression of plunger 300. In summary, a first depression of plunger 300simultaneously retracts needle 502 into device 100 while extendingj-wire 508. Upon releasing plunger 300, a second depression of plunger300 expands dilator 700.

The first depression of plunger 300 pushes prongs 306 in a distaldirection to press prong interfaces 308 against the angled surface offirst cam interface 402. As prongs 306 continue to advance in a distaldirection, the action of prong interfaces 308 pressing against theangled surface of first cam interface 402 causes cam 400 to perform afirst rotation. The first rotation of cam 400 is guided by rotationgroove 412 moving along cam translation catch 210. Cam 400 can berotated between about 15° and 180° from its starting position, such asabout 60°. As cam 400 rotates, j-wire groove 418 at the proximal end ofcam 400 is placed in alignment with j-wire catch 506 and needle groove420 at the distal end of cam 400 is placed in alignment with needlecatch 500. The alignment permits j-wire catch 506 to be pushed distallyfrom plunger 300 into j-wire groove 418 by way of the compressed springin plunger 300, pushing j-wire 508 out of the distal end of device 100.In some embodiments, the alignment between j-wire catch 506 and j-wiregroove 418 occurs after a 30° rotation of cam 400. The alignment alsopermits needle catch 500 to be pushed proximally from plunger connector600 into needle groove 420 by way of the compressed spring in plungerconnector 600, retracting needle 502 from the distal end of device 100.In some embodiments, the alignment between needle catch 500 and needlegroove 420 occurs upon completion of the first rotation of cam 400.Releasing plunger 300 springs plunger 300 to its starting position,which releases prongs 306 from cam 400 and permits the proximal movementof needle catch 500 within needle groove 420 to perform a secondrotation of cam 400. The second rotation of cam 400 aligns second caminterface 404 with prongs 306, and also aligns translation groove 410with cam translation catch 210. In some embodiments, the second rotationis about 30°.

The second depression of plunger 300 pushes prongs 306 in a distaldirection to press prong interfaces 308 against the angled surface ofsecond cam interface 404. Due to the length of second cam interface 404,the advancement of prongs 306 and prong interfaces 308 in a distaldirection pushes cam 400 in a distal direction without rotating cam 400.The distal advancement of cam 400 is guided by translation groove 410moving along cam translation catch 210. As cam 400 advances, plungerconnector 600 is pushed through the curved distal section 252 of casing200, whereupon the distal end of plunger connector 600 pushes againsthead 710 of column 702 and advances column 702 in a distal direction. Ascolumn 702 advances in a distal direction, the movement of each strut704 attached to column 702 is constrained by each of the slits 260. Eachstrut 704 synchronously expands outwards, thereby expanding each wallmember 706 outwards. As the expansion of dilator 700 is directly linkedto the second depression of plunger 300, plunger 300 can providefeedback based on the resistance felt in depressing plunger 300. Forexample, increasing resistance to depressing plunger 300 generallyindicates increasing resistance (e.g., strength) at dilator 700, such asfrom the tracheal wall.

The various components of device 100 can be constructed from materialshaving sufficient strength, flexibility, machinability, surface finish,and biocompatibility for medical use, such as for emergencytracheotomies. Furthermore, the materials and configurations of thedevice are generally selected for fabrication costs, ease of use, andaccessibility. For example, in some embodiments, device 100 can beprovided in a basic configuration having a cheap and simple constructioncomprising only a casing 200 housing a plunger 300 directly engaging adilator 700, such that a single depression of plunger 300 is configuredto directly expand dilator 700 as described elsewhere herein.

The various components of device 100 can be manufactured according tomany methods, including additive manufacturing (e.g., 3D printing).Other types of manufacturing can be used, such as injection molding,casting, machining, and the like. For example, components substantiallycomprising a metal may be milled from a larger block of metal or may becast from molten metal. Likewise, components substantially comprising aplastic or polymer may be milled from a larger block, cast, or injectionmolded.

Methods of Percutaneous Dilation Tracheostomy

The present invention further includes methods of using the percutaneousdilation tracheostomy devices of the present invention. The devices areconfigured to incorporate several components that are typicallyseparate, simplifying three major steps of emergency tracheotomies:puncture of the trachea, dilation of the stoma and introduction of thetracheostomy tube.

Referring now to FIG. 18 , an exemplary method 800 is depicted. Method800 begins with step 802, wherein a percutaneous dilation tracheostomydevice of the present invention is provided having a tracheostomy tubefitted over a distal section of the casing. In step 804, an incision isformed on an anterior neck of a subject while palpating for cartilage ofthe trachea (shown in FIG. 19 (i)). In step 806, a needle of the deviceis inserted between the cartilage of the trachea (shown in FIG. 19(ii)). In step 808, a plunger is depressed to extend a j-wire and toretract the needle (shown in FIG. 19 (iii)). In step 810, the device isadvanced into the trachea such that wall members are positioned adjacentto the cartilage of the trachea. In step 812, the plunger is depressedto expand the wall members (shown in FIG. 19 (iv)). The wall memberspress against the patient's cartilaginous tracheal rings to dilate thepatient's stoma. In step 814, the tracheostomy tube is slid off of thedevice and into the trachea. In step 816, the device is removed from thetrachea (shown in FIG. 19 (v) and (vi)).

In some embodiments, step 808 can be preceded by a step of conducting abubble test. A syringe partially loaded with a liquid can be insertedinto the syringe port at the top of the plunger and drawn to confirm ifthe needle is in the patient's airway. If the needle is in the patient'sairway, air passes from the tip of the needle through the lumens of thedevice and into the syringe. The presence of bubbles passing through theliquid in the syringe confirms the needle is in the patient's airway andnot the surrounding tissue.

The method performs a percutaneous dilation tracheostomy procedure as intypical emergency tracheostomies, such as a Ciaglia Blue Rhino®.However, the improved percutaneous dilation tracheostomy device of thepresent invention allows an operator to perform the method steps ofpuncturing the patient with the needle, confirming proper puncture witha bubble test, retracting the needle, and dilating the patient'strachea. Thus, the method reduces the steps and time required tocomplete a percutaneous tracheotomy compared to a Seldinger techniqueand advantageously allows an operator to receive feedback from thedevice during the method. Furthermore, the dilation mechanism isconfigured to provide feedback from the dilation of the stoma, such asthe feedback of a Laborde dilator as typically used in open surgicaltracheostomies.

EXPERIMENTAL EXAMPLES

The invention is further described in detail by reference to thefollowing experimental examples. These examples are provided forpurposes of illustration only, and are not intended to be limitingunless otherwise specified. Thus, the invention should in no way beconstrued as being limited to the following examples, but rather, shouldbe construed to encompass any and all variations which become evident asa result of the teaching provided herein.

Without further description, it is believed that one of ordinary skillin the art can, using the preceding description and the followingillustrative examples, make and utilize the compounds of the presentinvention and practice the claimed methods. The following workingexamples therefore, specifically point out exemplary embodiments of thepresent invention, and are not to be construed as limiting in any waythe remainder of the disclosure.

Example 1: Prototype and Dilator Stress Test

Prototypes were manufactured using a 3D printer (e.g., MakerBot). Theprinter used an ABS plastic ink, although other inks or resins may beused, such as PLA and the like. Manufacturing the device with a 3Dprinter also included forming temporary supports, such as wax supports,within the device, such as in a hollow interior of the casing to supportthe components in a given position. Removing the temporary wax supportsincludes heating the casing and placing the casing in an ultrasonictank.

A finite element analysis (FEA) was performed on the dilator wallmembers, struts, and central column to evaluate mechanical performance.The FEA constrained the wall members to zero degrees of freedom at thehinge pin connections and applied a pressure of 15 MPa to an exterior ofthe wall members to mimic the pressure of a tracheal wall upon dilation.The wall members were analyzed as having material properties ofstainless steel. The FEA similarly constrained each of the struts andthe central column and applied a pressure of 15 MPa to the interior ofthe hinge pin connections to simulate tracheal dilations. FIG. 20Aillustrates one wall member stress values. FIG. 20B illustrates onestrut stress values. FIG. 20C illustrates one central column stressvalues.

The disclosures of each and every patent, patent application, andpublication cited herein are hereby incorporated herein by reference intheir entirety. While this invention has been disclosed with referenceto specific embodiments, it is apparent that other embodiments andvariations of this invention may be devised by others skilled in the artwithout departing from the true spirit and scope of the invention. Theappended claims are intended to be construed to include all suchembodiments and equivalent variations.

1-21. (canceled)
 22. A percutaneous dilation tracheostomy devicecomprising: a hollow casing having an elongate cylindrical proximalsection and a curved tubular distal section; a plunger mechanism housedwithin the casing; a rotatable cam positioned within the proximalsection of the casing distal to the plunger mechanism; a dilatingmechanism positioned in the curved tubular distal section, mechanicallycoupled to the plunger mechanism; a flexible needle coupled to theplunger mechanism and extendable out of the hollow casing; and a lumenrunning from a proximal end of the proximal section to a distal tip ofthe distal section.
 23. The device of claim 22, the rotatable camfurther comprising a j-wire catch.
 24. The device of claim 23, furthercomprising a flexible j-wire connected to the j-wire catch at a proximalend and extendable out of the distal tip.
 25. The device of claim 22,the rotatable cam further comprising a needle catch.
 26. The device ofclaim 25, further comprising a flexible needle connected to the needlecatch at a proximal end and extendable out of the distal tip.
 27. Thedevice of claim 22, wherein the plunger mechanism comprises adepressible cylindrical plunger having a proximal end and a distal endpositioned within the proximal section of the casing, the plungercomprising a portion of the lumen.
 28. The device of claim 22, whereinthe distal tip comprises a tapered outlet.
 29. The device of claim 22,the dilating mechanism comprising a plurality of wall members positionedon an exterior surface of the curved tubular distal section.
 30. Thedevice of claim 29, the wall members configured to be expandable betweena retracted configuration that positions each wall member flush againstthe exterior surface of the curved tubular distal section and anextended configuration that positions each wall member at an adjustabledistance radially outward from the exterior surface of the curvedtubular distal section.
 31. The device of claim 30, wherein each of theplurality of wall members is radially equidistant from the lumen in theextended configuration.
 32. The device of claim 30, the dilatingmechanism further comprising a dilator column hingedly connected to aplurality of struts, each wall member being hingedly connected to twostruts of the plurality of struts.
 33. The device of claim 32, theplunger mechanism comprising a plunger depressible to advance thedilator column in a distal direction to move the wall members from theretracted configuration to the extended configuration.
 34. The device ofclaim 22, further comprising an elongate flexible plunger connectorpositioned within the proximal section of the casing distal to the cam,extending into the distal section of the casing.
 35. The device of claim34, wherein the elongate flexible plunger connector comprises a portionof the lumen.
 36. The device of claim 22, wherein the plunger mechanismcomprises a plunger configured to rotate the cam.
 37. The device ofclaim 22, further comprising a side port positioned in the proximalsection of the casing, the side port fluidly connected to an outlet ofthe distal tip.
 38. The device of claim 22, wherein the distal sectionof the casing has an outer diameter between 5 mm and 25 mm.
 39. Thedevice of claim 22, wherein the dilating mechanism is configured todilate a diameter of the curved tubular distal section by between 3 mmand 15 mm.
 40. The device of claim 22, wherein the dilating mechanism isconfigured to support an applied pressure of at least 15 MPa whenexpanded.
 41. The device of claim 22, wherein a first rotation step ofthe rotatable cam is configured to extend a j-wire stop and a j-wire,and to retract a needle stop and a needle.